Form 143 Authorization to Conduct Inspection on Tribal or Indian Land - Nebraska

Form 143 or the "Authorization To Conduct Inspection On Tribal Or Indian Land" is a form issued by the Nebraska Liquor Control Commission.

The form was last revised in July 1, 2015 and is available for digital filing. Download an up-to-date Form 143 in PDF-format down below or look it up on the Nebraska Liquor Control Commission Forms website.

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AUTHORIZATION TO CONDUCT INSPECTION
ON TRIBAL OR INDIAN LAND
Office Use
NEBRASKA LIQUOR CONTROL COMMISSION
TH
301 CENTENNIAL MALL SOUTH, 5
FLOOR
PO BOX 95046
LINCOLN, NE 68509-5046
PHONE: (402) 471-2571
FAX: (402) 471-2814
Website: www.lcc.nebraska.gov
PROPOSED PREMISE INFORMATION
Applicant name: ________________________________________________________________________
Trade name: ____________________________________________________________________________
Premise address: ________________________________________________________________________
City, State, Zip Code: _____________________________________________________________________
County: ________________________________
Nature of business: ______________________________________________________________________
I _________________________________________, hereby authorize any local
governing body, law enforcement officer, fire inspector or health inspector to
conduct an inspection which is required to license the premise for the sale or
consumption of alcohol.
______________________________________________
______________________________
Signature of Applicant
Date
BARCODE
LABEL
FORM 143
REV JULY 2015
PAGE 1
AUTHORIZATION TO CONDUCT INSPECTION
ON TRIBAL OR INDIAN LAND
Office Use
NEBRASKA LIQUOR CONTROL COMMISSION
TH
301 CENTENNIAL MALL SOUTH, 5
FLOOR
PO BOX 95046
LINCOLN, NE 68509-5046
PHONE: (402) 471-2571
FAX: (402) 471-2814
Website: www.lcc.nebraska.gov
PROPOSED PREMISE INFORMATION
Applicant name: ________________________________________________________________________
Trade name: ____________________________________________________________________________
Premise address: ________________________________________________________________________
City, State, Zip Code: _____________________________________________________________________
County: ________________________________
Nature of business: ______________________________________________________________________
I _________________________________________, hereby authorize any local
governing body, law enforcement officer, fire inspector or health inspector to
conduct an inspection which is required to license the premise for the sale or
consumption of alcohol.
______________________________________________
______________________________
Signature of Applicant
Date
BARCODE
LABEL
FORM 143
REV JULY 2015
PAGE 1

Download Form 143 Authorization to Conduct Inspection on Tribal or Indian Land - Nebraska

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